Experts have given evidence in the second part of coroner Wallace Bain's inquest into the death of 3-year-old Moko Rangitoheriri, at Rotorua's District court. One of the witnesses included Children's Commissioner Judge Andrew Becroft.
A minute silence was observed to remember those victims of the US shootings in Vegas before evidence was given.
Judge Andrew Becroft highlighted concerns regarding the agency support given to Moko's caregiver Tania Shailer, who was sentenced for the toddlers manslaughter.
"Skilled and competent front line social workers trained in a child focused approach, at least some of them would not have missed those what have been red flags," said Judge Becroft.
Concerns were also echoed by Coroner Bain and addressed Oranga Tamariki's Bay of Plenty regional manager, who spoke of the care and protection changes since toddler Nia Glassie's death in 2007.
"Primary recommendation in my view has not and that was there was no process in New Zealand to register under five," said Cr Bain. "My view that's just so basic. Have you got a comment on that?"
"Somebody knows that child exists, said . Whānau and family know that that child exists. And we need to get our community more actively involved," said Tayleva Petley.
Six experts gave an analysis on the evidence of some key witnesses during the first part of the inquiry in August, to assist Coroner Bain make recommendations to stop a death like this happening again.
"At the end the responsibility for our children lies with the family. With the family," said former Women's Refuge CEO, Merepeka Raukawa-Tait.
"We have to get to our families and if they are vulnerable and at risk. That's where the support should go."
One of two key recommendations by Judge Becroft is establishing a core competency of shared skills, values and knowledge across the children's workforce, to ensure warning signs aren't missed.